Surgical Club of South West England Meeting held at Weston-super-Mare 21 st October 1983

It has been established that 85-90% of upper G.I. bleeds stop spontaneously, either before or soon after hospital admission, and the value of routine endoscopy in all patients has been questioned. We admitted 94 patients with well documented bleeding in an eighteen month period, 75% of whom underwent endoscopy within 24 hours. The remaining 25% were not endoscoped either because they required immediate surgery or because they were considered too ill from other medical conditions. Ten patients had operations, 4 of whom died, 2 in the group who had been endoscoped, from associated medical problems, and 2 in the non-endoscopy group, both from bleeding following surgery. The remaining patients were either well at follow-up or had returned to their homes elsewhere in the

It has been established that 85-90% of upper G.I. bleeds stop spontaneously, either before or soon after hospital admission, and the value of routine endoscopy in all patients has been questioned.
We admitted 94 patients with well documented bleeding in an eighteen month period, 75% of whom underwent endoscopy within 24 hours. The remaining 25% were not endoscoped either because they required immediate surgery or because they were considered too ill from other medical conditions. Ten patients had operations, 4 of whom died, 2 in the group who had been endoscoped, from associated medical problems, and 2 in the non-endoscopy group, both from bleeding following surgery. The remaining patients were either well at follow-up or had returned to their homes elsewhere in the country.
During the past 10 years there has been a considerable reduction in the operation rate for patients presenting with upper G.I. bleeding. This may partly be explained by the increased association of bleeding with the use of non steroidal anti-inflammatory drugs?40% in this study.
We conclude that routine endoscopy is of value in upper G.I. bleeding as: (1) An accurate diagnosis may be made in about 95% of patients if endoscoped within 24 hours of admission.
(2) Stigmata likely to indicate re-bleeding may be identified.
(3) If re-bleeding does occur, surgery may be undertaken with the diagnosis known.

POST-OPERATIVE BLADDER IRRIGATION
A. Hinchliffe, Weston-super-Mare General Hospital In order to prevent or deal with clot retention after prostatectomy the Bristol Urologists developed a closed system of bladder drainage with irrigation.
The aim was to avoid bladder syringing and catheter changing which increased the risk of infection (or bacteraemia if infection was already established). The system, now over 20 years old, depends on the Higginson's syringe and irrigation reservoir to allow intermittent bladder lavage as necessary. We have redesigned it in disposable form using transparent materials including a more resilient bulb than the Higginson's and incorporating a 5 litre drainage bag.
No extra dripset or bag is necessary so the cost in use is little more than resterilisable hospital made sets.
Although anaesthetic management and modern endoscopic instruments have improved haemostasis during and after prostatectomy, the system is recommended for: (1) Open prostatectomy.
(3) Unexpected post-operative clot retention. (4) Spontaneous clot retention if there has to be any delay in surgical intervention. There is general agreement that improvement in career structure has become urgent. The suggestions currently under discussion with Government are: (1) Expansion in consultant numbers where there is a real job to be done, as a preliminary to other changes.
(2) The present Senior Registrar numbers would be appropriate to a moderately expanded consultant grade.
(3) Registrar numbers should be trimmed to correspond closely with SR vacancies, with the FRCS essential for appointment.
(4) Possibly some increase in SHO numbers, with the major element of competition for surgical careers taking place between SHO and Registrar grades. (5) A properly organised system of training for overseas doctors by a sponsorship scheme linked to return home after training. The additional numbers of trainees would be particularly valuable at Registrar level. The situation is complicated by the current lack of the resources to expand the consultant grade, seen 68 Bristol Medico-Chirurgical Journal April 1984 by the profession as the essential preliminary to the other changes.
Reduction in junior hours of work is an additional complication, made necessary by a serious threat of legislation, if the profession cannot achieve it. However, reduction of ? to ^ rotas depends upon the maintenance of standards of patient care and the final decision is for the consultant concerned.
HYPOCALCAEMIA AFTER SUB-TOTAL THYROIDECTOMY FOR THYROTOXICOSIS N. I. Ramus, Bristol Royal Infirmary To protect the recurrent laryngeal nerve during subtotal thyroidectomy for thyrotoxicosis the inferior thyroid artery should be ligated in continuity, laterally in the neck. It has been suggested that this approach results in parathyroid devascularisation and permanent hypocalcaemia and should be abandoned for ligation of the arterial divisions on the surface of the gland. Before this major change in practice was accepted the results from a teaching hospital were reviewed. Eighty one patients who underwent sub-total thyroidectomy for thyrotoxicosis had a 10% incidence of symptomatic hypocalcaemia (corrected calcium <2.0mmol/L) but only a 1.2% incidence of prolonged hypocalcaemia. In the same patients only 1 had a transient right sided recurrent nerve palsy. Five of the eight symptomatic patients required intravenous calcium postoperatively. Only one of these patients was a routine four vessel ligation, the others were a recurrent thyrotoxicosis and three patients who became hypocalcaemic despite only one inferior thyroid artery being ligated in two cases and neither inferior artery in the other.
These results would seem to confirm the wisdom of lateral ligation of the inferior thyroid artery to protect the recurrent laryngeal nerve. They lend no support to the suggestion that in order to protect parathyroid function this teaching be abandoned in favour of a policy of ligation of the arteries on the surface of the gland. There has been an absolute increase in both the incidence and number of deaths from acute pancreatitis in Bristol with an increase in alcohol-related disease. The case mortality of a first attack has remained the same despite modern resuscitative methods and subsequent attacks appear more lethal. *(X2 = 35.56 DF = 1) IMPLANTATION (12), povidone-iodine (7) and water (12); noxythiolin, sodium hypochlorite and silver nitrate are used occasionally. The mean duration of treatment is 2 minutes. When assayed for cytotoxicity against tumour cells, prepared from colorectal carcinomas (n = 10), chlorhexidine-cetrimide (Savlodil) and povidone-iodine (Betadine) were lethal at a wide range of concentrations (5-100% of stock solution). Mercuric perchloride (0.2%) was similarly effective, the Region to support the Register and perform the pre-operative assays.
Chemotherapy and Radiotherapy protocols have been kept under constant review by the Group. There is now a tendency towards a shorter simpler course of cytotoxic drugs with obvious advantages to the patients. There is a review of the position and use of Radiotherapy in the treatment of tumours. Coincidental to this has been the development of interest in the place of abdominal lymphadenectomy for residual bulk disease. Techniques involved in the excision of this secondary tumour are being developed and it is hope, they will be standardised in the Region, possibly using one of two Centres. The Study Group wishes to thank all those surgeons who have supported it during its formative years, and now that it is established, would encourage any still uncertain to join the Register and admit their patients accordingly.
CRYPT CELL PRODUCTION RATE IS FASTER IIM ALL PHASES OF ULCERATIVE COLITIS COMPARED WITH NORMAL MUCOSA

A. Allan, Bristol Royal Infirmary
If an increased colonic cell production rate should occur in patients with ulcerative colitis, this might contribute to the increased incidence of colonic cancer seen in colitic patients. We report in-vitro culture of rectal mucosa from patients with ulcerative colitis, followed by measurement of crypt cell production rate CCPR in the cultured biopsies. Organ culture of rectal biopsies were carried out for 16 hour followed by a further 3 hour over Vincristine-containing medium. Electron microscopy revealed good preservation of histological architecture during culture. Vincristine arrested dividing cells in metaphase and following crypt microdissection these metaphase figures were counted to derive the CCPR.
Linear accumulation doses of metaphase figures by cultured biopsies was observed (P<0.001).
Optimal doses of Vincristine to induce metaphase arrest in normal and colitic mucosa were established.
The CCPR in mucosa from patients with ulcerative colitis in relapse is significantly faster than the CCPR in mucosa from patients with colitis in remission or normal mucosa. The increased CCPR seen in all Laparoscopy although well established in gynaecology has gained limited acceptance in general surgery. It is simple, safe and cost-effective in staging and assessing operability. The accuracy rate of liver scintigraphy, ultrasound and CT scanning, single or composite is 80%. Surgery for oesophageal and gastric carcinoma has a high morbidity, mortality and statistically low cure rate. A prospective study of the accuracy of liver scintigraphy, ultrasound scanning and laparoscopy, and their effect on management was undertaken. Accuracy was determined by laparoscopic biopsy, laparotomy and autopsy. Fifty patients were studied: 23 oesophageal carcinoma, 14 gastric carcinoma, 13 suspected disseminated intra-abdominal malignancy. The accuracy was 72, 75.5 and 96% for scintigraphy, ultrasound and laparoscopy respectively, with 10% failed ultrasound due to gas. There was one failed laparoscopy due to adhesions and no morbidity or mortality. Laparoscopy revealed nodal and peritoneal spread in 15 patients. Laparotomy was avoided in 58%, and 74% died in the 18 month follow-up period. A preliminary laparoscopy will obviate the need for laparotomy in inoperable cases and allow better planning for potentially curable surgery. This avoids the morbidity and mortality of an exploratory laparotomy and the discomfort and emotional trauma of these patients with advanced disease with low cure rates. Flexible fibreoptic sigmoidoscopy is an extremely useful investigation in the elucidation of large bowel pathology. This study examines the practicality of carrying out this procedure on unprepared bowel in the general surgical outpatients in a District General Hospital and discusses our early experience. Fifty patients with symptoms of large bowel disease were submitted to flexible fibreoptic sigmoidoscopy. The examination was entirely successful in 38 patients. Of the 12 unsatisfactory examinations 5 (10%) were due to faecal obstruction, 6 to diverticular disease and 1 to carcinomatous stricture. We suggest that the advantages of flexible fibreoptic sigmoidoscopy include: early diagnosis of pathology, assessment of the 'doubtful sigmoid', patient comfort and reduction in barium enemas. The disadvantages are: cost (initial outlay of ?3000), time (10-30mins for examination and recycling of equipment), space, skill and training of nursing staff, small biopsies.
In summary we believe that flexible fibreoptic sigmoidoscopy can be used effectively in the unprepared bowel in the general surgical outpatient clinic giving an impressive yield of pathology leading to early definitive treatment and a reduction in requests for barium enemas.
The last 3 papers were selected out of 11 entrants for the S.W. Surgical prize.